Ontario Public Health Units Research Articles

A cost comparison of electronic and hybrid data collection systems in Ontario during pandemic and seasonal influenza vaccination campaigns

BackgroundDuring the pandemic (H1N1) 2009 influenza vaccination campaign, health regions in Canada collected client-level immunization data using fully electronic or hybrid systems, with the latter comprising both electronic and paper-based elements. The objective of our evaluation was to compare projected five-year costs associated with implementing these systems in Ontario public health units (PHUs) during pandemic and seasonal influenza vaccination campaigns.MethodsSix PHUs provided equipment and staffing costs during the pandemic (H1N1) 2009 influenza vaccination campaign and staffing algorithms for seasonal campaigns. We standardized resources to population sizes 100,000, 500,000 and 1,000,000, assuming equipment lifetime of five years and public health vaccine administration rates of 18% and 2.5% for H1N1 and seasonal campaigns, respectively. Two scenarios were considered: Year 1 pandemic and Year 1 seasonal campaigns, each followed by four regular influenza seasons. Costs were discounted at 5%.ResultsAssuming a Year 1 pandemic, the five-year costs per capita for the electronic system decrease as PHU population size increases, becoming increasingly less costly than hybrid systems ($4.33 vs. $4.34 [100,000], $4.17 vs. $4.34 [500,000], $4.12 vs. $4.34 [1,000, 000]). The same trend is observed for the scenario reflecting five seasonal campaigns, with the electronic system being less expensive per capita than the hybrid system for all population sizes ($1.93 vs. $1.95 [100,000], $1.91 vs. $1.94 [500,000], $1.87 vs. $1.94 [1,000, 000]). Sensitivity analyses identified factors related to nurse hours as affecting the direction and magnitude of the results.ConclusionsFive-year cost projections for electronic systems were comparable or less expensive than for hybrid systems, at all PHU population sizes. An intangible benefit of the electronic system is having data rapidly available for reporting.

Uncovering Tacit Knowledge: A Pilot Study to Broaden the Concept of Knowledge in Knowledge Translation

BackgroundAll sectors in health care are being asked to focus on the knowledge-to-practice gap, or knowledge translation, to increase service effectiveness. A social interaction approach to knowledge translation assumes that research evidence becomes integrated with previously held knowledge, and practitioners build on and co-create knowledge through mutual interactions. Knowledge translation strategies for public health have not provided anticipated positive changes in evidence-based practice, possibly due in part to a narrow conceptualization of knowledge. More work is needed to understand the role of tacit knowledge in decision-making and practice. This pilot study examined how health practitioners applied tacit knowledge in public health program planning and implementation.MethodsThis study used a narrative approach, where teams from two public health units in Ontario, Canada were conveniently selected. Respondents participated in individual interviews and focus groups at each site. Questions were designed to understand the role of tacit knowledge as it related to the program planning process. Data were analyzed through a combination of content analysis and thematic comparison.ResultsThe findings highlighted two major aspects of knowledge that arose: the use of tacit knowledge and the integration of tacit and explicit knowledge. Tacit knowledge included: past experiences, organization-specific knowledge, community contextual knowledge, and the recognition of the tacit knowledge of others. Explicit knowledge included: research literature, the Internet, popular magazines, formal assessments (surveys and interviews), legislation and regulations. Participants sometimes deliberately combined tacit and explicit knowledge sources in planning.ConclusionsThis pilot demonstrated that front-line public health workers draw upon both tacit knowledge and explicit knowledge in their everyday lived reality. Further, tacit knowledge plays an important role in practitioners' interpretation and implementation of explicit research findings. This indicates a need to broaden the scope of knowledge translation to include other forms of knowledge beyond explicit knowledge acquired through research. Strategies that recognize and support the use of tacit knowledge, such as communities of practice or networks, may be important components of a comprehensive approach to knowledge translation. This study provides support for further investigation of the role of tacit knowledge in the planning and delivery of effective public health services.

Nurse Practitioner Role Implementation in Ontario Public Health Units

Objectives: To identify the barriers and facilitators associated with the implementation of the nurse practitioner (NP) role in Ontario’s public health units (PHUs), the NPs’ job satisfaction, and the relationship between NP job satisfaction and practice dimensions. Methods: This descriptive study involved a postal survey of all NPs (N=29) working in Ontario PHUs. Results: Twenty-eight (96.5%) NPs completed the survey. The facilitators to role implementation most often identified by the NPs were management support, the NPs’ knowledge of the PHU programs, and access to PHU programs for their clients. The barriers most often cited were being the only NP working in the PHU, inadequate salary, and lack of coverage when the NP was away. When working with community physicians, the most common facilitators were the trust shown by physicians when making shared decisions and physician respect for the NP. The most common barriers were the unwillingness of specialist physicians to accept referrals from the NP and physicians’ lack of understanding of the role. Overall, the NPs were satisfied with working in the PHU, satisfied with their collaborative relationship with physicians and minimally satisfied with their salaries. Conclusion: NPs have recently been introduced in PHUs in Ontario. A number of factors have facilitated role integration. At the same time, a number of barriers to their role implementation have been identified and if addressed, can contribute to the optimal utilization of this role in PHUs. Key words: Nurse practitioners; public health; primary health care; role implementation; job satisfaction

Prevalence and antimicrobial resistance in Campylobacter spp. isolated from retail chicken in two health units in Ontario.

Campylobacter is an important enteric pathogen of humans and can cause diarrhea, fever, and abdominal pain. Campylobacter infections have frequently been associated with the handling and consumption of raw and undercooked poultry. Antimicrobial resistance among Campylobacter strains is of concern in the treatment of campylobacteriosis in vulnerable populations. A 2-year multidisciplinary study was conducted in the Perth and Wellington-Dufferin-Guelph public health units in Ontario, Canada, to investigate the prevalence and antimicrobial resistance of Campylobacter spp. in retail chicken. Retail chicken samples were collected from randomly selected stores in these health units. Resulting Campylobacter isolates were tested for susceptibility to amoxicillin-clavulanic acid (AMC), ampicillin (AMP), chloramphenicol (CHL), ciprofloxacin (CIP), clindamycin (CLI), erythromycin (ERY), gentamicin (GEN), nalidixic acid (NAL), tetracycline (TCY), and trimethoprim-sulfamethoxazole (SXT) using the E test. The prevalence of Campylobacter in 1,256 retail chicken samples was 59.6%. Of these positive samples, 9% contained Campylobacter coli, 1% contained Campylobacter lari, and 90% contained Campylobacter jejuni. Of the chicken isolates that were resistant to one or more antimicrobial agents, 301 isolates (40%) were resistant to one agent, 374 (50%) were resistant to two, 39 (5%) were resistant to three, 20 (3%) were resistant to four, and 6 (1%) were resistant to five. Nine isolates (1%) were susceptible to all antimicrobial agents tested. All isolates were susceptible to AMC, CHL, and GEN. Less than 10% of isolates were resistant to NAL, CIP, CLI, ERY, and AMP. Resistance to TCY was common (56%). No isolates had a resistance pattern that included all three antimicrobials important in the treatment of human campylobacteriosis (CIP, ERY, and TCY); however, 24 isolates (3.2%) were resistant to at least two of these antimicrobials.

Feasibility and utility of mapping disease risk at the neighbourhood level within a Canadian public health unit: an ecological study

BackgroundWe conducted spatial analyses to determine the geographic variation of cancer at the neighbourhood level (dissemination areas or DAs) within the area of a single Ontario public health unit, Wellington-Dufferin-Guelph, covering a population of 238,326 inhabitants. Cancer incidence data between 1999 and 2003 were obtained from the Ontario Cancer Registry and were geocoded down to the level of DA using the enhanced Postal Code Conversion File. The 2001 Census of Canada provided information on the size and age-sex structure of the population at the DA level, in addition to information about selected census covariates, such as average neighbourhood income.ResultsAge standardized incidence ratios for cancer and the prevalence of census covariates were calculated for each of 331 dissemination areas in Wellington-Dufferin-Guelph. The standardized incidence ratios (SIR) for cancer varied dramatically across the dissemination areas. However, application of the Moran's I statistic, a popular index of spatial autocorrelation, suggested significant spatial patterns for only two cancers, lung and prostate, both in males (p < 0.001 and p = 0.002, respectively). Employing Bayesian hierarchical models, areas in the urban core of the City of Guelph had significantly higher SIRs for male lung cancer than the remainder of Wellington-Dufferin-Guelph; and, neighbourhoods in the urban and surrounding rural areas of Orangeville exhibited significantly higher SIRs for prostate cancer. After adjustment for age and spatial dependence, average household income attenuated much of the spatial pattern of lung cancer, but not of prostate cancer.ConclusionThis paper demonstrates the feasibility and utility of a systematic approach to identifying neighbourhoods, within the area served by a public health unit, that have significantly higher risks of cancer. This exploratory, ecologic study suggests several hypotheses for these spatial patterns that warrant further investigations. To the best of our knowledge, this is the first Canadian study published in the peer-reviewed literature estimating the risk of relatively rare public health outcomes at a very small areal level, namely dissemination areas.

Planning a coordinated local health care system response to a pandemic using an accelerated Delphi technique: phase 1.

To coordinate local responsibilities and identify options to enhance local health system capacity during a pandemic. The purpose of this paper is to illustrate the application of a Delphi exercise in an Ontario Public Health Unit as a first step in this complex planning task. Its strengths and weaknesses are presented. Stakeholders representing nine categories of health care organizations. Public Health facilitated the Delphi process. The exercise occurred in three rounds. In round 1, stakeholders identified a series of questions pertaining to the subject. Round 2 involved formulation of issue-related statements outlining possible strategies or solutions. Level of agreement regarding the statements by panel members were indicated. In round 3, a facilitated face-to-face meeting allowed statements to be fed back to the panel, enabling discussion of their own and other panel members' previous statement views. Statements were formulated from questions generated by the expert panel, collated into categories and sent to all panel members. A total of 72 unique statements were developed. Agreement was obtained for 56 of the statements. The Delphi exercise proved to be an effective approach to commence planning a coordinated local health system response to a pandemic. This process permitted advancement of the planning exercise to Phase 2 which aimed to develop operational plans for primary assessment centres, alternate care sites and hospital surge capacity.

Assessing the Impact of a Municipal Pesticide Use Bylaw: A Quasi-Experimental Evaluation

ISEE-631 Objective: To assess initial impacts of a municipal bylaw restricting the nonessential use of chemical pesticides outdoors. Materials and Methods: We devised a “pre-during” quasiexperimental design using data from the Rapid Risk Factor Surveillance System, an ongoing monthly telephone survey of approximately 100 adult residents, administered in English by an independent research organization on behalf of participating Public Health units in Ontario, Canada. Health units may choose to collect information on lawn care practices using standardized questions. In the intervention jurisdiction (“I”), data was collected immediately before and following the first phase of bylaw implementation, which included education campaigns and education-based enforcement. The comparison jurisdiction (“C”) was the only other jurisdiction that collected the same data over the same time period; it had no pesticide bylaws during the data collection period. Survey information about the summer of 2003 constitutes the “pre” data (nI1 = 608; nC1 = 690), and information about the summer of 2005 is the “during” data (nI2 = 1043; nC2 = 811). Results: In the intervention jurisdiction the overall proportion of households reporting any pesticide use on their lawns decreased by 35%, from 37% ± 5% of households with lawns in 2003 to 24% ± 7% in 2005. Fewer householders themselves applied pesticides on their lawns (down from 25% ± 5% to 18% ± 3% across years), and lawn care companies used pesticides at substantially fewer households (from 60% ± 11% of the households served in 2003 to 36% ± 7% in 2005). In the comparison jurisdiction, the overall number of households reporting any pesticide use on their lawns decreased by only 9%. Conclusions: Preliminary data suggest that the bylaw has effectively decreased the proportion of households using pesticides to care for their lawns. More conclusive evidence will require a longer period of comparable data collection in these jurisdictions and in other jurisdictions with and without pesticide bylaws.

Public Health Decision‐Makers' Informational Needs and Preferences for Receiving Research Evidence

The purpose of this study was to identify decision-makers' preferences for the transfer and exchange of research knowledge. This article is focused on how the participants define evidence-based decision-making and their preferences for receiving research evidence to integrate into the decision-making process. Semistructured interviews were conducted with a purposive sample of 16 Ontario public health decision-makers from six Ontario public health units in this fundamental qualitative descriptive study. The sample included nine program managers, six directors, and one Medical Officer of Health. Participants were asked to define the term evidence-based decision-making and identify preferred research dissemination strategies. The interviews were audio-taped, transcribed verbatim, and coded for emerging concepts. Participants defined evidence-based decision-making as a process whereby multiple sources of information were consulted before making a decision concerning the provision of services. To facilitate integration of research evidence into the decision-making process, public health administrators appreciate receiving, in both electronic and hard copy, systematic reviews, executive summaries of research, and clear statements of implications for practice from health service researchers. Although consensus exists among participants concerning the definition of evidence based public health decision-making, ongoing efforts are required to continue to promote the use of research evidence in program planning and public health policy. It is also important to continue to improve the ease with which public health decision-makers access systematic reviews, as well as to ensure the relevance and applicability of the results to the practice setting.

Case Study: Nursing Professional Practice Councils: The Quest for Nursing Excellence

The quest for nursing excellence requires enthusiasm, commitment and a dedicated team of nurses. The desire to create an environment where nurses were valued, supported and empowered led to the development of a Nursing Professional Practice Council within an Ontario Public Health Unit. The journey is described in detail, from planning and implementation through lessons learned and recommendations for organizations embarking on a similar quest. As a direct result of the Nursing Professional Practice Council, experiences within the organization have exceeded expectations, justified the financial costs and improved relationships among all parties.

Income inequality and health in Ontario: a multilevel analysis.

To examine the association of income inequality at the public health unit level with individual health status in Ontario. Cross-sectional multilevel study carried out among subjects aged 25 years or older residing in 42 public health units in Ontario. Individual-level data drawn from 30,939 respondents in 1996-97 Ontario Health Survey. Median area income and income inequality (Gini coefficient) calculated from 1996 census. Self-rated health status (SRH) and Health Utilities Index (HUI-3) scores were used as main outcomes. Controlling for individual-level factors including income, respondents living in public health units in the highest tercile of income inequality had odds ratios of 1.20 (95% CI 1.04 - 1.38) for fair/poor self-rated health, and 1.11 (95% CI 1.01 - 1.22) for HUI score below the median, compared with people living in public health units in the lowest tercile. Controlling further for median area income had little effect on the association. Income inequality was significantly associated with individual self-reported health status at public health unit level in Ontario, independent of individual income.

Income Inequality and Health in Ontario

To examine the association of income inequality at the public health unit level with individual health status in Ontario. Cross-sectional multilevel study carried out among subjects aged 25 years or older residing in 42 public health units in Ontario. Individual-level data drawn from 30,939 respondents in 1996–97 Ontario Health Survey. Median area income and income inequality (Gini coefficient) calculated from 1996 census. Self-rated health status (SRH) and Health Utilities Index (HUI-3) scores were used as main outcomes. Controlling for individual-level factors including income, respondents living in public health units in the highest tercile of income inequality had odds ratios of 1.20 (95% CI 1.04–1.38) for fair/poor self-rated health, and 1.11 (95% CI 1.01–1.22) for HUI score below the median, compared with people living in public health units in the lowest tercile. Controlling further for median area income had little effect on the association. Income inequality was significantly associated with individual self-reported health status at public health unit level in Ontario, independent of individual income.

Comparison of Papanicolaou (Pap) Test Rates Across Ontario and Factors Associated with Cervical Screening

Cervical cancer remains a significant yet preventable disease despite the widespread availability of Pap test screening, which detects cervical cancer and its precursor lesions. The aims of this study were to: i) estimate and compare age- and hysterectomy-adjusted Pap test rates across the 37 Ontario public health units (PHUs), and ii) explore the association between several factors and Pap test rates (at the ecological level). Cytobase, an Ontario Pap test registry, captures more than 80% of all Pap tests in Ontario. Cytobase was used to determine Pap test rates adjusted for age, hysterectomy and Cytobase coverage for the year 2001. Multiple linear regression analyses were used to evaluate the relationship between Pap test rates and various factors at an ecological level, Age-, hysterectomy- and Cytobase-adjusted one-year Pap rates ranged from 11.6% to 73.9% among PHUs. The overall rate for Ontario was 40.7%. Multivariate analyses indicated that the presence of a teaching hospital was associated with higher Pap test rates. One-year Pap test rates varied greatly across the 37 public health units in Ontario. Pap test rates determined using Cytobase were lower than self-reported rates obtained from the Canadian Community Health Survey, possibly due to "over-reporting". In general, women were not screened as frequently as recommended by the Ontario Cervical Screening Program. A positive association was observed between Pap test rates and the presence of a teaching hospital. Data quality issues limit the ability to monitor cervical screening. A provincial registry would address these issues.

An Evaluation of the Ontario Rapid Risk Factor Surveillance System

The Rapid Risk Factor Surveillance System (RRFSS) is an ongoing population health survey conducted by a collaborating group of Ontario public health units. This formative evaluation examined the process effectiveness, collaboration, utility and cost-effectiveness of RRFSS during its first year of operation. An Evaluation Framework was developed with reference to guidelines for evaluation of surveillance systems developed by the World Health Organization and the U.S. Centers for Disease Control and Prevention. The study focussed on evaluable performance areas in a young surveillance system and on information needed to inform stakeholder decisions about future participation and improvement. Data were collected through surveys and interviews of key informants in participating health units, non-participating health units, the survey research house, and the provincial health ministry. Findings documented early use and dissemination of RRFSS data in health units after less than a year of surveillance system operation, stakeholder perceptions overall of data impact and value, and satisfaction with system functioning. Challenges to effectiveness were documented concerning data analysis, barriers to data use, and sustainability. Performance improvement strategies were identified for survey implementation and supports, data use, system participation, and reduced costs. In its first year, RRFSS was an effective collaborative method to collect population data for public health program planning and evaluation. The evaluation provided valuable information on use, functioning, effectiveness, strategic issues and areas for improvement in a young surveillance system, created opportunities for stakeholder input into evaluation and planning, and provided a baseline for future evaluations.

“Interaction” and research utilisation in health policies and programs: does it work?

The objective of this study was to assess if interaction between users and producers of research is associated with a greater level of adoption of research findings in the design and delivery of health care programs. Responses to the dissemination of a research report on breast cancer prevention were compared between two groups of public health units in Ontario, Canada. Although all public health units received the report, only a subset of units was involved in the development of the report, while others were not. Research utilisation was conceptualized in terms of stages, including reading the report, information processing, and application of findings for public health units’ policies and programs. Using a multi-case study design, three units that contributed to the report's production (the interacting units) were compared with three units were not involved in producing the report (the comparison units) on the basis of research utilisation. Data collection involved group interviews and document review. Results demonstrated that interacting units had a greater understanding of the report's analysis and attached greater value to the report. However, interaction was not associated with greater levels of utilisation in terms of application. Both interacting and comparison units used the research findings to confirm that their on-going program activities were consistent with the research findings, and to compare their program performance relative to other units. In conclusion, interaction influenced the understanding of the research, and intent to use the research findings, but applied use was independent of interaction between producers and users of research.

Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada

Despite Canada's reputation as a leader in health promotion and population health concepts, actual public health practice for the most part remains wedded to downstream strategies focussed on behaviour change. In Canada's largest province this has led to the implementation of a heart health promotion approach focussed on diet, activity and tobacco use. This is so despite increasing evidence that these approaches are generally ineffective, particularly for those at greatest risk. In addition, these strategies appear to divert public and governmental attention away from addressing the broader societal determinants of health. Examples of Ontario public health units that have begun to address societal determinants of health provide a counterbalance to the dominant paradigm that frames health as an individual responsibility. These new approaches focus attention upon the health-threatening effects of governments' regressive social and economic policies in a manner consistent with the best principles of health promotion.

Learning to be a normal mother: empowerment and pedagogy in postpartum classes.

This qualitative study, which was conducted in the summer of 1992, presents the findings of how six first-time mothers and two public health nurses experienced pedagogical practices within postpartum classes offered by two public health units in Ontario, Canada. How concerns and aspirations of new mothers were constructed and mediated in the postpartum class are analyzed using concepts from poststructuralist and feminist methodologies. This study goes beyond an analysis of individual teaching and learning styles and discusses how social structures of isolation, investment in a medical discourse, and processes of normalization construct an individual's experiences and practices of mothering, which in turn influence pedagogical practices in postpartum classes. Issues of empowerment, language, support, and knowledge exchange are discussed.

FACTORS OF THE INNOVATION, ORGANIZATION, ENVIRONMENT, AND INDIVIDUAL THAT PREDICT THE INFLUENCE FIVE SYSTEMATIC REVIEWS HAD ON PUBLIC HEALTH DECISIONS

To determine the extent to which systematic reviews of public health interventions influenced public health decisions and which factors were associated with influencing these decisions. This cross-sectional follow-up survey evaluated the use of five systematic reviews in public health decision making. Independent variables included characteristics of the innovation, organization, environment, and individual. Primary data were collected using a telephone survey and a self-administered organizational demographics questionnaire. Public health decision makers in all 41 public health units in Ontario were invited to participate in the study. Multiple linear regression analyses on the five program decisions were conducted. The systematic reviews were perceived as having the greatest amount of influence on decisions related to program justification and program planning, and the least influence on program evaluation decisions. The greater the perception that one's organization valued the use of research evidence for decision making and that ongoing training in the critical appraisal of research literature was provided, the greater the perception of the influence the systematic review had on public health decisions. Organizational characteristics are important predictors of the use of systematic reviews in public health decision making. Future dissemination strategies need to promote the value of using systematic reviews for program decision making as well as promote ongoing training in critical appraisal among intended users in Ontario.

Determinants of implementing heart health: promotion activities in Ontario public health units: a social ecological perspective.

This paper reports the results of a study undertaken to explain levels of implementation of heart health promotion activities observed in Ontario public health agencies in 1997. Organizational-level data were collected by surveying all 42 health departments in 1994, 1996 and 1997 as part of the Canadian Heart Health Initiative Ontario Project. Guided by social ecological and organizational theories, the model examines relationships between implementation and four sets of possible determinants of activity: (1) the predisposition of agencies to undertake heart health promotion activities, (2) their capacity to undertake these activities, (3) internal organizational factors and (4) external system factors. A small set of five variables explains almost half of the variance in implementation (R2 = 0.46): organizational capacity (beta = 0.40), priority given to heart health (beta = 0.36), coordination of programs (beta = 0.19), use of resource centers (beta = 0.12) and participation in networks (beta = 0.09). The results suggest that models integrating organizational and socio-ecological theories can help us understand the implementation of community-based heart health promotion activities by public health agencies. Implications for future research, policy and practice are discussed.

Using Healthy Life Years (HeaLYs) to Assess Programming Needs in a Public Health Unit

In December 1997, public health units in Ontario received revised mandatory program guidelines from the Ministry of Health in advance of the downloading of public health to municipalities. Public health units face difficult decisions in allocating municipal resources to meet the Province's mandated programs. To set priorities for resource allocation, it is critical to assess need across program areas and to use a common unit in doing so. This paper applies the Healthy Life Years (HeaLYs) method in assessing health need related to the mandatory programs for the population of Wellington and Dufferin counties in Ontario. The HeaLYs method incorporates duration and severity of ill-health, incidence and mortality in calculating years of healthy life lost (YHLL). For Wellington-Dufferin, the leading causes of YHLL were concentrated in the program areas of chronic disease, injury, and substance abuse and included four areas not addressed in the MPG (suicide, depression, dementia, and osteoarthritis).

The Policy Context for Community Development Practice in Public Health: A Canadian Case Study

The Community Action in Public Health Study explored how public health managers, frontline staff, and community participants interpret, implement and receive policy guidelines urging collaboration with community groups in public health work. In-depth case studies of 6 public health units in Ontario, Canada focussed on 19 community development projects in 3 program areas (107 interviews). In the absence of formal policy guidelines on community development at provincial or local levels, informal policy predominated. Local senior management frequently set the tone, distinguishing health units in which community development was a basic philosophy underlying a broad spectrum of public health practice from those in which it was seen as only one among many possible strategies. Uncertainty and risk associated with informal policy lead many frontline staff to adopt strategies intended to preserve autonomy in community work, including "seeking forgiveness rather than permission" and maintaining relative "invisibility."